Ahmc Seton Medical Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of the 26 sampled residents (Resident 97) bed/side rail was raised up while the resident was in bed. This failure resulted in Resident 97 falling out of bed and sustain a fracture (broken bone) through the right femur (thigh bone). During an observation on 8/11/25, at 10:04 AM, Resident 97 was asleep in bed. The right and left upper bed/side rails were raised. During an interview on 8/13/25, at 10:08 AM, Registered Nurse (RN) 4 stated that the bed/side rails were raised up when Resident 97 is in bed for positioning. RN 4 further stated Resident 97 leans to one side. A review of the facility's Informed Consent for Bedrail Use - Facility verification Form indicated the consent was obtained on 6/29/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Interim Dietary Director (IDD), who is also a registered dietitian and oversees the kitchen, was fully sufficient when she did not ensure that auditing of the dish machine logs and cooling (Cooling is the specific method and guideline used to rapidly lower the temperature of cooked food to a safe storage level, preventing bacterial growth. Improper cooling is a major factor in causing foodborne illness. Taking too long to chill potentially hazardous food, which means food that requires time/temperature control for safety to limit the growth of pathogens, has been consistently identified as one factor contributing to foodborne illness. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure governing body oversight of the facility's Quality Assurance Program (QAPI) program and activities when plan of action to correct identified deficiencies were not implemented and maintained. This failure had the potential to negatively affect the care and services rendered to the residents, including their quality of life. Review of the facility's QAPI Meeting Minutes from September 2025 to November 2025 indicated, .Continue with POC (plan of correction) . The QAPI Meeting Minutes did not show any oversight of how the plan of action was being implemented to address the identified deficiencies. During an interview on 12/10/25 at 4:40 PM, Chief Clinical & Quality Officer (CCQO) stated that the Director of Nursing (DON) and Manager of the Subacute were responsible for the implementation of the plan of correction. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify on-going systemic issues, develop, implement, and evaluate its plan of action to correct the identified deficiencies when:The facility failed to report an alleged abuse incident involving Resident J within the required 2-hour timeframe. Additionally, the facility did not conduct a thorough investigation of the alleged abuse incident. (Cross reference to F609 and F610)The facility failed to report the results of investigation within five (5) working days of the incident for two reported abuse allegations involving Resident J, Resident L, and Resident M. (Cross reference to F609)The facility failed to evaluate, develop, and implement interventions after Resident A was identified with a significant weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when: 1. Multiple small packs of butter in a black container in the kitchen refrigerator had no expiration dates.2. Multiple small packs of butter in a stainless-steel container in the kitchen refrigerator were expired.3. The freezer temperature for the ice cream in the kitchen was out of range. 4. Six packs of MY OWN MEAL FLORENTINE LASAGNA in the kitchen storage room were expired. 5. The dish machine temperature log indicated the final rinse temperature was below 180 F (degrees Fahrenheit, a scale for measuring temperature) for multiple days in June and August 2025.6. The dish machine temperature was not checked for multiple days in June 2025. 7. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure valid copy of the Physician Orders for Life-Sustaining Treatment (POLST, a written medical order that assists people in making decisions about medical treatment and life saving measures during end-of-life care or medical crisis) for two of 26 sampled residents (Resident 5 and Resident 6) had complete and accurate information.1. For Resident 5, the POLST indicated Do Not Attempt Resuscitation (DNR, a medical order instructing healthcare professionals not to perform CPR (chest compressions, cardiac drugs, or intubation) if a person's heart stops or they stop breathing) and Selective Treatment, which conflicted with the physician's order stating, FULL CODE-DNR-Comfort Focused Treatment, resulting in inconsistent documentation regarding the resident's code status.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to safeguard the personal property for one of 3 sampled residents (Resident 63) whose cellphone was reported missing on 2/9/25. Additionally, the facility failed to ensure the missing cellphone was replaced in accordance with the facility's Theft and Loss Policy. These failures resulted in the loss of Resident 63's cellphone; and may disrupt communication with family and friends and decrease sense of safety and trust in the facility's ability to protect residents and their belongings. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported immediately, not later two (2) hours after the allegation was made, as required by regulation involving resident 77. This failure resulted in a delay in reporting an abuse allegation and had potential to place all residents at risk for further abuse. A review of Resident 77 clinical document, titled Nurses Notes, dated 5/6/2025 at 12:14PM, the Nurses Noted indicated, incident dated 4/26/2025: redness under the left eye) Bruise? Reported to law enforcement asked the case number then she said that the police will come to investigate. SOC 341 was faxed to the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation on an allegation involving physical and emotional abuse for one of 2 sampled residents (Resident J). Failure to thoroughly investigate an allegation of abuse did not ensure other residents were protected from abuse. A review of the face sheet indicated Resident J was admitted with diagnoses including injury to cervical (neck) spine, quadriplegia (loss of movement and sensation to arms and legs), osteoporosis (fragile bones), osteoarthritis (pain, swelling of the bones and joints), bipolar disorder (a mental illness that affects a person's energy, thoughts, and unusual shifts in mood from extremely highs [manic episode] to lows [depression], and anxiety (excessive, persistent feeling of worry and nervousness). [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA, is a comprehensive assessment for a resident that must be completed when the IDT (Interdisciplinary Team) has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 26 sampled residents (Resident 56) who had a significant change in status on 1/20/25. The deficient practice may result in delayed provision of care, treatment, and services for Resident 56. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 26 sampled resident's (Resident 97) Minimum Data Set (MDS, a standard assessment tool) included the medical diagnosis of osteopenia (fragile bones). This facility failure resulted in inaccurate MDS to reflect the current health status for Resident 97. A review of the physician progress notes dated 4/24/25, indicated the diagnoses for Resident 97 included dementia (decline in memory or other thinking skills), diabetes (abnormally high blood sugar level) and hypertension (abnormally high blood pressure). A review of the facility reported incident dated 5/4/25, indicated on 4/25/25, Resident 97 fell out of bed and sustained a fracture (broken bone) through the right femur (thigh bone). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 97) had a comprehensive care plan completed to address osteopenia (fragile bones). This facility failure had potential for Resident 97 to not receive necessary care and services. A review of the physician progress notes dated 4/24/25, indicated the diagnoses for Resident 97 included dementia (decline in memory or other thinking skills), diabetes (abnormally high blood sugar level) and hypertension (abnormally high blood pressure). A review of the facility reported incident dated 5/4/25, indicated on 4/25/25, Resident 97 fell out of bed and sustained a fracture (broken bone) through the right femur (thigh bone). [...]

Inspectors wroteBased on interview and record review, the facility failed to effectively assess, evaluate, and implement interventions consistent with the nutritional status for one of three sampled residents (Resident A) when:1. The facility did not initiate a change of condition report to address Resident A's weight loss of 7.8 pounds (lbs.) within a month after it was identified on 10/7/25. 2. The facility failed to develop a care plan to address Resident A's weight loss of 7.8 pounds as identified on 10/7/25.3. Weekly weight evaluations were not implemented in accordance with the facility's policy.4. There was no documented follow up assessment, actions, or interventions by a Registered Dietitian (RD, a health professional with special training in diet and nutrition) to address Resident A's weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed their infection control policy and procedure (P &P), when a Licensed Vocational Nurse (LVN) did not perform hand hygiene between glove changes during medication administration. This failure had the potential to expose residents to cross contamination and increase the risk of infection. During medication administration observation on 8/13/2025 at 10:04AM, room [ROOM NUMBER], LVN1 was preparing medications wearing gloves, LVN 1 was observed removing her gloves, checking the computer and donning a new pair of gloves without performing hand hygiene. During an interview on 8/13/2025 at 10:15 AM, LVN 1 acknowledged forgot to do hand hygiene before putting on a new pair of gloves, yes I know I should perform hand hygiene first. [...]

Inspectors wroteBased on observation, interview, and record review, four problems were identified regarding the facility's fall prevention program: 1. The facility did not regularly conduct a thorough investigation regarding the primary causes of falls for Resident 1. 2. The facility did not conduct a fall risk assessment for two of Resident 1's falls. 3. The facility continued using a tab alarm (an alarm that clips onto a resident's clothing) to alert staff for unassisted transfers for Resident 1 who has a history of unclipping the tab alarm from her clothing. The facility did not evaluate if a tab alarm was appropriate for Resident1 in decreasing her fall risks. 4. Staff did not consistently implement interventions within Resident 1 's care plans to minimize fall risks for Resident 1 (application of tab alarm or activation of bed alarm). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave or hospitalization) to four of four sampled residents (Resident 1, 2, 3, and 4) or their responsible party (RP) at the time of transfer to acute care hospital. This failure could result in residents and/or their RP not being fully informed of their right to request a bed hold and to return to the facility after hospitalization, potentially leading to inappropriate discharge.

Inspectors wroteBased on observation, interview and record review, the facility did not thoroughly investigate a grievance regarding administration of tube feeding formula as ordered by the physician for Resident 1, one of three sample residents. The facility ' s investigation was not thorough because they failed to : 1. Consider the maximum rate their tube feeding pump could run at (295 ml/hr, mililiter per hour, milliliter= unit of fluid measurement). 2. Identify an unclear tube feeding physician order. The tube feeding order directed staff to administer each feeding (325 ml) within an hour. Given the maximum rate of the pump, it was impossible to infuse the ordered amount with the pump alone within the time frame specified. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure ulcer (PU) for one of 14 sampled residents (Resident 22) when interventions were not implemented to avoid skin breakdown for Resident 22. This deficient practice resulted in the development of Stage 2 PU for Resident 22. Definition/Stages for Pressure Ulcer/Pressure Injury (also called a bed sore, is an injury to skin and underlying tissue resulting from prolonged pressure on the skin. Stage I: Intact skin with a localized area of non-blanchable redness (non-blanchable: redness persists and does not fade or turn white after removal of fingertip pressure). Stage II: Partial-thickness loss of skin with exposed upper skin layer. The wound bed is pink. May also present as an intact or ruptured blister. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of eight sampled residents (Residents 409, 70, and 86) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when the facility did not ensure: 1. Resident 409 a. was free from side effects due to the use of Haldol. Haldol is an anti-psychotic drug used to treat symptoms of psychosis. Symptoms of psychosis includes hallucinations (perceiving sights, sounds, smells, tastes, or touches that are not real), delusions (false beliefs), and dementia (loss of the ability to think, remember, learn, make decisions, and solve problems). b. Aggressive behaviors were managed via non-medication means such as modifying smoking rules. c. Haldol dosage was not lowered for 96 days when side effects were first identified. 2. Resident 70 a. [...]

Inspectors wroteBased on interviews and record reviews, facility staff failed to treat three out of 24 sampled residents with dignity (Residents 6, 82, and 408) when these residents have to wait 30-45 minutes for staff to answer their request/call light for assistance. Failure to answer a resident's call light in a timely manner did not ensure these residents were treated in a dignified manner.

Inspectors wroteBased on interview and record review, the facility failed to inform residents about the facility's grievance process. Seven out of seven sampled residents were not aware of the grievance process (Residents 5, 19, 24, 32, 55, 57, and 72). For Resident 408, the facility failed to complete the resolution review of the grievance process. Failure to inform or follow the grievance process, did not ensure concerns from the residents or their responsible parties were addressed in an appropriate and timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments for three of 24 sampled residents (Residents 4, 6, and 13) were accurate when; 1. The Minimum Data Set (MDS - an assessment tool) for Resident 4's dental assessment was inaccurate. 2. The MDS indicated Resident 6's hemodialysis treatment was inaccurate. 3. The MDS indicated Resident 13 had three pressure ulcers when there was only one. Failure to complete accurate assessments could potentially harm the residents by not providing needed care and services to maintain their highest level of functioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan (CP) for each resident that included measurable objectives and specific interventions for seven of 24 sampled residents (Residents 4, 7, 70, 78, 38, 407, and 6) when: 1. No individualized person-centered CP was developed for Resident 4's pain due to unfit dentures. 2. No individualized person-centered CP was developed for Resident 7's use of Lovenox (a blood-thinning drug used to prevent formation of blood clots). 3. No individualized person-centered CP was developed for Resident 70's use of Zolpidem (a medication primarily used for the treatment of sleeping problems). 4. CP did not reflect the use of gloves, tab and bed alarms for Resident 78. 5. CP did not reflect management of planned weight loss for Resident 38. 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM) for four of 14 sampled residents (Residents 12, 22, 38, and 14) when the physician's order for ROM exercises was not implemented. This deficient practice had the potential to limit the residents' ROM or possible development/worsening of a contracture. According to a Medical Dictionary, retrieved from http://medical dictionary.thefreedictionary.com/range+of+motion+exercise, on 2/16/24, indicated, . Range of motion is one aspect of exercise important for increasing or maintaining joint function . Passive range of motion is movement applied to a joint solely by another person or persons or a passive motion machine. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a sanitary environment by neglecting to properly clean one of the four fixed kettles between serving porridge and soup for lunch. Additionally, kitchen prep surface drainage holes, encrusted with dried, unidentifiable food particles, were exposed and untreated. This failure had the potential to result in potential health risks to residents.

Inspectors wroteBased on observation and staff interview, the facility failed to provide for a community dining and activity area on the 4th floor, 5th floor, and 7th floors, resulting in residents being confined to their rooms for all meals.

Inspectors wroteBased on observation and interview, the facility failed to ensure a shower area was clean after use and two window screens were missing. Failure to clean a shower after use,and properly maintained window screens did not ensure residents were provided with a clean, comfortable, homelike environment. Lack of a window screen has the potential for flying pest to come into a resident's indoor living space.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the pharmacy consultant's recommendation for the use of psychotropic medication was acted upon for one of eight sampled residents (Resident 86). This failure had the potential for Resident 86 to receive unnecessary psychotropic medications, be exposed to adverse health consequences from the medications, which could negatively impact the residents' mental, physical, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate record for 3 of 24 sample residents (Resident 25, 396, and 397). For Residents 25 and 397, staff failed to document their fluid intake accurately. For Resident 396 an anti-psychotic target behavior was documented incorrectly. Failure to accurately document fluid intake or target behavior has the potential for the care team to act or recommend treatment based on inaccurate information.

Inspectors wroteBased on interview and record review, the facility failed to ensure education regarding protective vaccine were documented and follow up and/or refusals were documented in two of four sampled resident's records (Residents 70 and 88). Failure to document education did not ensure residents and/or their responsible parties could make an informed decisions regarding vaccines. Failure to follow up and/or document refusals did not ensure residents healthcare choices were honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure education regarding protective vaccine were documented and follow up and/or refusals were documented in two of four sampled resident's records (Residents 13 and 89). Failure to document education did not ensure residents and/or their responsible parties could make an informed decisions regarding vaccines. Failure to follow up and/or document refusals did not ensure residents healthcare choices were honored.

Inspectors wroteBased on observation and interview, an emergency cart plastic lock tag did not match the lock tag documented on the log. Failure to follow procedure regarding logging lock tags did not ensure emergency devices and/or supplies would be available in the event of an medical emergency.

Inspectors wroteBased on observation and interview, the facility failed to have a secure handrail in their corridor. Failure to maintain handrails did not ensure residents who relied on handrails for mobility and/or support would be safe from a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary, comfortable and homelike environment when: 1. The linoleum flooring in room [ROOM NUMBER]'s bathroom were torn, cracked, and peeling off around the base of the toilet exposing the subfloor and had a pungent musty odor. 2. 20 of 41 resident bathroom flooring (Rooms 101, 105, 111, 201, 206, 208, 301, 302, 305, 306, 308, 309, 310, 311, 401, 403, 406, 407, 408 and 410) were damaged and discolored. 3. There was an evidence of stagnant, dark colored liquid in the shower room (number) 3 with pungent musty odor on the missing tiles. The pungent musty odor had caused Resident 91 to feel sick and want to throw up. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident comfort is achieved in accordance with comprehensive person-centered care plan when physician's order of No turning on Right Side was not implemented for one of 33 sampled residents (Resident 33). The deficient practice resulted in Resident 33 having a headache and discomfort, and had the potential to cause further brain tissue injury and increase intracranial pressure (pressure inside the skull).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide preventative treatment, equipment, and services to maintain, improve, and prevent further decline in range of motion (ROM) and/or mobility when: 1. The physician's order for hand splint and rolled bath blanket at lumbar spine were not implemented for Resident 33. The deficient practice resulted in pain, further increase in contractures, and decline in ROM for Resident 33. A contracture is a condition of shortening and hardening of muscles, tendon or other tissue, often leading to deformity and rigidity of joints which limit and interfere with daily functioning. 2. The Physical Therapist (PT) recommendation to ambulate with staff supervision was not implemented for Resident 46. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide training to all nursing staff how to perform range of motion (ROM) exercises to residents in accordance with the facility policy. (Refer to F 688) This failure could potentially delay the identification of issues and provision of care to prevent further decline of resident's functional status.

Inspectors wroteBased on interview and record review, the facility failed to develop and document an individualized (own) facility-wide assessment (assessment of resident care needs) to determine resources needed to care for its resident population. The lack of development and documentation of a facility-wide assessment had potential to affect the care and safety of all residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure all portions of the residents' call light system was functioning to communicate resident calls from all residents' rooms and all bathrooms to the call system's computer placed at the nursing station. This failure had a potential to delay all resident call communications between residents and staff, delaying staffs' response to residents' urgent needs, with the potential to expose all residents to adverse events (unexpected injury, harm, death or risk thereof), and compromising their health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident's visual privacy for one out of 33 sampled residents (Resident 238) when the privacy curtain was not pulled and the door to the resident's room was left wide opened, exposing his diaper and legs. This deficient practice had the potential to negatively affect resident's dignity and could potentially cause feeling of being shameful.

Inspectors wroteBased on observation, interview, record review the facility failed to develop a comprehensive care plan (CCP) that included measurable objectives and timeframe for five (5) out of 33 sampled residents (Residents 135, 44, 77, 35 and 137) when: 1. For Resident 135, there was no evidence a comprehensive care plan for Dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) was developed. 2. For Resident 44, there was no evidence skin care plan was developed to address left abdominal fold abrasion and right upper buttock abrasion. 3. For Resident 77, there was no evidence skin care plan was developed to address abdominal folds rash. 4. For Resident 35, there was no evidence a CCP was developed to address the use of restraint (is any physical or chemical means or device that restricts resident's freedom). 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from a medication error rate of 5 percent or greater for six of 8 sampled residents (Resident 538, 123, 539, 540, 541, and 115) during medication pass observation when: 1. For Resident 538, Registered Nurse (RN) 3 did not give Fluticasone nasal spray (a medicine used to treat allergy or non-allergy nasal symptoms such as runny nose, and sneezing) as per the manufacturer's instructions, 2. For Resident 123, Licensed Vocational Nurse (LVN) did not rotate injection sites of Copaxone (glatiramer acetate, a medicine that is used to treat multiple sclerosis, a disease that impacts the brain and nerves) as per manufacturer's instructions (Refer to F755), 3. For Resident 539, 540, 541, and 115, RN 2 prepared medications for four Residents at the same time. [...]

Inspectors wroteBased on observations, interview and record review the hospital failed to ensure a Registered Dietitian (RD) provided frequent oversight of food and nutrition services and consultation to the Kitchen Supervisor which resulted in deficient practices related to the competency of foodservice staff for the following: a. Cooldown monitoring of foods capable of supporting bacterial growth associated with foodborne illness; b. Safe storage of refrigerated foods; c. Provision of timely and relevant dietary staff training related to the scope and nature of foodservice operations and d. Consistent use of standardized recipes These failures had the potential to lead to foodborne illness in a highly susceptible population for greater than 50 residents at the [NAME] and Coastside campuses who received food from the kitchen.

Inspectors wroteBased on food production operations the facility failed to employ sufficient and competent support personnel to implement foodservice operations as evidenced by 1) lapses in food production standards and 2) departmental position vacancies. Failure to ensure sufficient and competent dietetic services staff may result in unsafe food production practices putting residents at risk for foodborne illness and decreased meal intake further compromising medical status.

Inspectors wroteBased on meal distribution observations the facility failed to follow the menu when the portion sizes for 6 residents (Residents 38, 72, 97, 115, 242 and 243) at the [NAME] campus with physician ordered mechanically altered diets were not correct. Failure to follow the facility approved menu may result in decreased nutritional intake further compromising medical status.

Inspectors wroteBased on dietetic services operations, dietary staff interview and departmental document review the facility failed to ensure food safety standards when there was lack of 1) effective cooldown monitoring of potentially hazardous foods 2) lack of date receiving of foods capable of foodborne illness as well as shelf stable foods; 3) food storage practices that may promote cross contamination; 4) lapses in handwashing procedures; 5) lack of adequate air gaps in food production equipment at both the [NAME] and Coastside campus; and 6) retention of damaged products. Failure to provide a food production environment that is safe and sanitary may result in foodborne illness, cross contamination of food and equipment and use of expired ingredients that may affect flavor and/or texture of food. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) identified on-going systemic issues, develop and implement appropriate plans of action to correct the identified quality deficiencies when: 1. Resident's bathrooms at [NAME] Coastside were identified to have pungent odor, peeling, cracking of vinyl flooring, and water leak were not addressed. (Refer to F 584) 2. Failed to maintain functional call light system at [NAME] Coastside since 9/30/21. (Refer to F 919) 3. The performance improvement plan did not fully reflect actions to address identification of lapses in safe food handling practices and maintenance of the dietary physical environment. (Refer to F 803, 812 and 908) 4. Evaluation of residents population and identification of the resources needed to provide the necessary care and services was not conducted. [...]

Inspectors wrote3. The facility failed to follow COVID screening in accordance with their mitigation plan for all visitors and staff. During an observation on 2/7/22 at 8:30 AM, the Security Officer (SO) responsible for screening, did not screen three CDPH Surveyors, visitors, and hospital personnel. During an interview with SO on 2/8/22 at 8:40 AM, stated he was not instructed on screening for COVID. During an interview on 2/8/22 at 11:00 AM, the Infection Preventionist (IP) stated he had provided a complete packet with screening instructions to the Security Manager. He indicated the Security Manager was responsible for distributing the information to all Security Officers working at the Main Entrance to the facility. A record review of a document titled Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities indicated HCP (health care personnel) Screening: [...]

Inspectors wroteBased on dietetic services observations, dietary and administrative staff interview and departmental document review the facility failed to ensure essential dietetic services equipment was functional at both the [NAME] and Coastside locations when there were multiple pieces of equipment that have been non-functional from 2 months to greater than 12 months. Failure to maintain equipment in a safe and functional manner may affect the ability for the department to operate in a safe and effective manner which may result in nutritional risk to residents. This has the potential to affect the efficient delivery of meal services to 108 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of 33 sampled residents (Resident 37) who was at risk for fall. This deficient practice had the potential to result in falls, injury, and harm to the resident and not meeting Resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure their abuse prevention policy and procedure was implemented when there was no evidence of background screening for two nursing staff (CNA 4 and LVN 8). Failure to implement abuse prevention policy had the potential to compromise the resident's health, safety, and well-being.

Inspectors wroteBased on interview and record review the facility failed to report an alleged abuse incident in a timely manner for one of six sampled residents (Resident 132) with abuse allegation incidents when Certified Nursing Assistant (CNA) 7 reported the alleged verbal abuse two days after the incident. The facility failure to report abuse according to the required timeframe had the potential to delay the identification and implementation of appropriate corrective action that may place the residents at risk of abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the Minimum Data Set (MDS) accurately reflect the functional status of two of 13 sampled residents (Residents 66 and 65). MDS is an assessment tool that serves as the clinical basis for care planning and delivery of care and services Failure to complete accurate assessment could potentialy result in inappropriate care planning, ineffective interventions and/or delay in provision of needed care and services to maintain residents highest level of functioning.

Inspectors wroteBased on interview and record review the facility failed to ensure the baseline care plan (BCP) summary was provided to one of 33 sampled residents (Residents 241) when there was no evidence a summary of there BCP was provided to the resident and/or the responsible party. This deficient practice had the potential to place the resident at risk to not receive the quality of care and the appropriate interventions and goals to maintain the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement their wound care policy for two of 33 sampled residents (Resident 44 and 77), when: 1. Staff did not develop a non-pressure skin report and the nursing weekly summary did not indicate Resident 44's new skin condition. 2. Staff did not develop a non-pressure skin report and did not complete a nursing weekly assessment to address Resident 77's abdominal folds rash. This failure could potentially result in a negative outcome for Resident 44 and 77.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains free of hazards when sharp objects were observed in plain sight in the room of one of 25 sampled residents (Resident 30). This failure had the potential to cause accident and harm when accessed by other residents.

Inspectors wroteBased on interview and record review, the facility failed to evaluate and implement interventions that are consistent with the nutritional status for one of four sampled residents (Resident 111) when: 1. Staff rely on the caregivers verbal report of Resident 111 meal intake percentage with no verification. 2. There was no Registered Dietitian (RD, a health professional with special training in diet and nutrition) nutritional assessment and progress notes addressing Resident 111's nutritional status for the month of February, March, and April 2022 and weight loss on March and April 2022. 3. The nursing staff did not document and communicate to the Medical Doctor (MD) and RD to address Resident 111's significant weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of eight sampled residents (Resident 123) when Licensed Vocational Nurse (LVN) did not rotate injection sites of Copaxone (glatiramer acetate, a medicine that is used to treat multiple sclerosis, a disease that impacts the brain and nerves) as per manufacturer's instructions. This failure may result to skin and fatty tissue irritation.

Inspectors wroteBased on observation, interview and record review the facility failed to provide food at required temperature for residents. This failure had the potential to place residents at risk for poor food intake which could compromise their nutritional and health status.

Inspectors wroteBased on interviews and record reviews, the Skilled Nursing Facility (SNF) failed to ensure that staff educated and documented in residents medical records education regarding the risk and benefits of vaccinations, for one out of 33 sampled residents, Resident 35. This failure had a potential to expose Resident 35 to lack of information needed to make informed choices regarding immunization, increasing Resident 35 to the likelihood of suffering from adverse events (unanticipated injuries, harm, death or risk of infectious diseases) related to infectious diseases, and compromising her health and safety.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure to ensure all staff were fully vaccinated for COVID-19 (a new infectious viral disease that can cause respiratory illness) when: 1. There was no evidence proof of vaccination were obtained for four (4) facility staff (Staff 1, Staff 2, Staff 3 and Staff 4). 2. Staff vaccination rate was less than 100%. Failure to track and document COVID-19 vaccination status of all staff could potentially increase risk of spreading infection in the facility.